Last reviewed: 20 Sep 2020
Last updated: 08 Feb 2018



History and exam

Key diagnostic factors

  • presence of risk factors
  • disturbed cognition during event (confusional arousals, sleep terrors, sleepwalking)
  • vigorous activity or violent behaviour (confusional arousals, sleepwalking, sleep terrors, and rapid eye movement sleep behaviour disorder [RBD])
  • episodes of inability to move (isolated recurrent sleep paralysis)
  • autonomic hyperactivity during event (sleep terrors)
  • amnesia
  • normal physical examination between episodes

Other diagnostic factors

  • abnormal demeanour and facial expression (confusional arousals, sleepwalking, sleep terrors)
  • evidence of injuries

Risk factors

  • FHx of NREM parasomnias (confusional arousals, sleepwalking, sleep terrors)
  • presence of HLA gene DQB1*05 and *04 alleles (sleepwalking)
  • psychiatric medications or alcohol
  • hx of psychiatric disorder
  • fever
  • acute sleep deprivation or irregular sleep-wake schedule disorder
  • emotional stress and traumatic life events
  • forced awakenings
  • untreated comorbid sleep disorders
  • premenstrual state (in adolescent girls)

Diagnostic investigations

1st investigations to order

  • clinical examination
  • polysomnography (rapid eye movement sleep behaviour disorder)
More 1st investigations to order

Investigations to consider

  • polysomnography (confusional arousals)
  • polysomnography (sleepwalking)
  • polysomnography (sleep terrors)
  • polysomnography (nightmare disorder)
  • polysomnography (all other parasomnias)
  • polysomnography with expanded EEG video recording
  • urine drug screen
More investigations to consider

Treatment algorithm


Co-Director, Pediatric Sleep and Research Center

Cardinal Glennon Childrens Hospital

Associate Professor of Neurology

Saint Louis University School of Medicine

St Louis



RM declares that he has no competing interests.

Co-Medical Director, Sleep Medicine and Research Center

St. Luke's Hospital

Adjunct Associate Professor

Department of Pediatrics

Saint Louis University School of Medicine

St Louis



SP receives royalties from UpToDate for writing two topics: diagnosis and management of pediatric obstructive sleep apnea.

Dr Raman Malhotra and Dr Shalini Paruthi would like to gratefully acknowledge Dr Alon Y. Avidan, the previous contributor to this monograph. AYA has been paid honorarium speaking fees by the American Academy of Sleep Medicine, the American Academy of Neurology, the American College of Chest Physicians, Sepracor Inc, Cephalon Inc, and Pfizer Pharmaceuticals.

Peer reviewersVIEW ALL

Consultant in Paediatric Neurodisability

Evelina Children's Hospital

St Thomas' Hospital




PG is lead applicant on the ongoing MENDS trial, which is concerned with the use of melatonin in children with neurodevelopmental disorders and impaired sleep.

Reader in Psycho-Social Intervention

Centre for Evidence Based Intervention

Barnett House

University of Oxford




PM has received funding greater than 6 figures USD from the Swedish Board of Health and Welfare, Martek Biosciences, Danish Social Research Institute, UK Department of Health, UK Health Technology Assessment Programme. PM declares that he has no competing interests.

Associate Professor of Pediatrics


Division of Pulmonary and Sleep Medicine

Department of Pediatrics

Medical College of Wisconsin

Medical Director

Pulmonary Clinic

Children's Hospital of Wisconsin




LAD declares that she has no competing interests.

Use of this content is subject to our disclaimer